GW1--05454_Well Construction - GW1_20240912

WELL CONSTRUCTION RECORD(GW-11 6.......„„__For Internal Use Only: I
1.Well Contractor Information: I
Chris King
Well Contractor Name 14.WATER ZONES
FROM TO
DESCRIPTION
• 2080-A 160". IGa ft.
J O Gleiri
NC Well Contractor Certification Number ft. ft.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO.... DIAMETER THICKNESS MATERIAL
Company Name0 ft• S O ft.
16 /�C/ In, �Spit>11 VI v :c.
T �-. cA 16.INNER CASING OR TUNING(geothermal closed-loop)
9
2.Well Construction Permit#: ` 0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/Q', 'oantr.State,variance.etc.) ft. ft. in.
3.Well Use(check en'ell use): ft. ft. in.
Water Supply Well: 17,SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Municipaljpublic it• H- in.
Geothermal(Hcating/Cooling Supply) W; csidcntial Water Supply(single)
Industrial/Commercial ft. R. In.
®°Residential Water Supply(shared) 18.GROUT
litigation FROM TO MATERIAL EMPLACEMENT METHOD di AMOUNT Non-Water Supply Well: CD Ct. ft.
Monitoring �Recovcry � r�x'�U h�i�� ilW
•Injection Well: ft H
Aquifer Recharge ? Groundwater Renhediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK(If applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
ft. ft.Geothent:al(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothcnnal(Heating/Cooling Return) i-)Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,soiUroe&(Noe.grab]size,eta)
® ft. 6 ft. sitej
/ 1I 4.Date Well(s)Completed: -tom Well iD# / ft. CS- ft. nizd .i1 Kid A7 4 c iT
5a.Well Iacatlou: q5- ft. �•1e25-(•t. i•2r lu c &tZM)a- !e�-CI
ft. of ft. N
Facilitv'O vt:-:Name Facility
ft. ft. �.;. •�
• 4
•2 l i I fr. ft. a •; 1,,... .
Physicalicj Address,City,and Zip ft. ft. S t P 1 2
,It/� }��- 1. 21.REMARKS 2024
County Ile,:v rig: : i'rr,.:/ ',-a
:, {'
Parcel Identification No.(P1N) C ` y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: y . `�
(if well field.one latllong is sufficient)
22.Certification:
N W
6.Is(arc)the walks'��j4Permanent or OTemporary S «tee ofCenified Well Contractor % -6:_ `�
Date
this firm.I
7.Is this a repr lr to an existing well: Dyes or o with signing5A C IC 0?C.0100 or 1S4tNC4C 02Cat the.0200dlfell Construc was(mow) tion n Standards onstructed in and that a
if this is a r ytir,•liil out known,well construction inf„rmathn,and explain the nanny alike coin•of this record has bean proridcd to the'It'll owner.
repair under F?l remarks section or on the bark of this faint.
23.Site diagram or additional well details:
8.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constructicr.:.only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
�- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft.) Z
For multiple wells list all depths ifdil/e eta(example-3ka200'and 2*(00•) For All Wells: Submit this form within 30 days of completion of well
construction to the following: I
10.Stark water level below top of casing: (ft.) Division of Water Resoiirccs,Information Processing Unit,
If water level is above erasing.use'•+••
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) • 24b.For infection Wells: In addition to sending the form to the address in 24a
12.Weil construction method: Jig ( ij) ` above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
•
e construction to the following:
FOR WA:- SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
/) 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.:':eld(;pea) (/ Mi ethod of test: 1• Yl �- 24c.For Water Supply/lc infection Wells: In addition to sending the form to
fri�%r I / the addresses) above, also submit One copy of this form within 30 days of
13b.Disin i:c/iea type: 11 Amount: Lag completion of well construction to the county health department of the county
where constructed.
Font;C W-t Nonlr.Camlina pepartmcnt of Environmental Quality-Division of Water Resources
Revicrd 9_99_9n l A